Vaginal delivery of breech presentation : No. 226, June 2009

Objectives

To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth.

Options

Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean section for women with a singleton breech fetus at term.

Outcomes

Reduced perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short- and long-term maternal morbidity and mortality.

Evidence

Medline was searched for randomized trials, prospective cohort studies, and selected retrospective cohort studies comparing planned Caesarean section with a planned trial of labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean section. Additional articles were identified through bibliography tracing up to June 1, 2008.

Values

The evidence collected was reviewed by the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the criteria and classifications of the Canadian Task Force on Preventive Health Care.

Validation

This guideline was compared with the 2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery.

Sponsors

The Society of Obstetricians and Gynaecologists of Canada.     

Safety and efficacy of external cephalic version for women with a previous cesarean delivery

Objective

To evaluate the success and morbidity rates for attempted external cephalic version (ECV) in patients with one previous cesarean delivery (CD) and a breech-presenting fetus at term.

Study design

This is a retrospective study of outcomes of ECV at our institution for all women with one previous CD and a breech-presenting fetus at term between January 1997 and June 2005. A literature review was also performed as a Medline search (1966–2006).

Results

ECV was attempted for 42 women with a breech-presenting fetus and previous CD. The success rate of ECV was 74.0%, and 84% of women with successful ECV delivered vaginally. All fetal and maternal outcomes were favorable. Only four Medline reports met our inclusion criteria, representing a total of 124 patients and a mean ECV success rate of 76.6%. Thus we assessed 166 cases of attempted ECV and find an average ECV success rate of 76.5% and favorable fetal and maternal outcomes.

Conclusions

Women with a breech-presenting fetus at term and previous CD, who desire a trial of labor, should be counseled regarding the accumulating evidence about the efficacy and apparently safety of this procedure and may be offered an ECV attempt.     

The complications of external cephalic version: results from 805 consecutive attempts

Most breech babies at term are now delivered by caesarean section. Although external cephalic version reduces the number of term breech presentations, its uptake has not been as wide as is recommended by professional bodies. This may be because of fears over safety. Pooled safety data do exist, largely from case series. However, the possibility of reporting and publication biases in such studies maybe preventing both women and obstetricians from being adequately reassured. In this series of 805 consecutive version attempts, we report an extremely low complication rate and 0.5% risk of emergency caesarean section after the procedure.     

Head entrapment and neonatal outcome by mode of delivery in breech deliveries from 28 to 36 weeks of gestation

OBJECTIVES: We attempted to determine whether there are differences in the incidence of head entrapment and adverse neonatal outcome by mode of delivery in breech deliveries from 28 to 36 weeks of gestation. STUDY DESIGN: Computerized data and charts of 321 viable consecutive singleton breech deliveries from 28 to 36 weeks' gestation were reviewed. Statistical methods used included χ², logistic regression, and analysis of variance. RESULTS: Head entrapment occurred in 4 of 52 (7.7%) neonates delivered vaginally and 14 of 269 (5.2%) neonates delivered by cesarean section (p = 0.48). There were no statistically significant associations between head entrapment and adverse neonatal outcomes. CONCLUSIONS: There was no significant difference in the incidence of head entrapment by mode of delivery for breech infants at 28 to 36 weeks' gestation, nor was there an association with adverse neonatal outcomes after entrapment. (Am J Obstet Gynecol 1996;174:1742-9.)     

小儿臀及会阴部烫伤的护理

目的:总结86例小儿臀部烫伤的临床护理经验,提高护理质量,加快创面愈合.方法:臀、会阴部烫伤的患儿采取人字型体位,俯卧于特制的海绵垫上,双腿分开外展60°,做好创面的护理,加强大小便管理,规范使用美宝湿润烧伤膏(MEBO).结果:本组86例患儿均采用MEBO治疗及人字型体位法处理,全部临床治愈,无1例创面感染及并发症发生.结论:通过总结分析,认为MEBO是目前处理烫伤创面较理想的药物,采用人字型体位,也是处理小儿会阴部烫伤较科学的体位.     

Mothers' views of their childbirth experience two years after term breech delivery

Introduction. This study was performed to evaluate mothers' views of their childbirth experience two years after term breech delivery.

Methods. Two years after delivery mothers were asked to fill out a questionnaire concerning their breech birth experience and their view about the care provided to them while giving birth. Outcomes of the planned cesarean section (CS) group were compared with outcomes of the planned vaginal delivery (VD) group, whether or not a vaginal birth was realized or an emergency cesarean section was performed. Any differences were further analyzed by use of logistic regression, controlling for potential confounders.

Results. Significantly more women in the planned CS group were reassured about their baby's health (67.4% vs. 37.9%, p = 0.0006) at the time of delivery, whereas more women in the planned VD group recalled having been worried about their baby's health at the time of delivery (45.0% vs. 25.6%, p = 0.02). Also, more women in the planned VD group experienced more pain during labor and delivery than expected (46.9% vs. 18.5%, p = 0.008). In the planned VD group fewer women indicated they had an active say in decision-making (59.1% vs. 85.3%, p = 0.001).

Conclusions. Evaluation of the mothers' views of their childbirth experience two years after term breech delivery showed that more women in the planned VD group recalled having been worried about their child's health at the time of delivery, experienced more pain than expected, and reported less involvement in decision-making.     

Cesarean or vaginal delivery for the breech fetus at the threshold of viability: results from a maternal–fetal medicine specialists survey

Objective.?To determine how United States Maternal–Fetal medicine specialists recommend delivery of a breech fetus at the threshold of viability.

Methods.?U.S. Society for Maternal–Fetal Medicine (SMFM) members were surveyed about; geographic location, practice type, whether they performed deliveries, definition of threshold for viability, recommendations for delivery of a breech fetus at the threshold of viability, and if the current medical–legal climate had any bearing on their decisions. Chi-Square and Fisher's Exact tests were used for analysis.

Results.?510 SMFM members responded to the questionnaire. The highest percentage of respondents stated ‘23 weeks’ (31%) as the cutoff for viability, followed by ‘24 weeks’ (21%) and ‘23 weeks or 500 g’ (10%). Seventy percent recommended cesarean delivery for a breech fetus at the threshold of viability. The majority of respondents based their decision on ‘published data’ or ‘expert opinion’, however, 58.6% reported they felt current medical evidence was inadequate to support a recommendation. Fifty-three percent stated their recommendations are affected by medical–legal concerns.

Conclusion.?The majority of U.S. maternal fetal–medicine specialists who responded would recommend cesarean delivery for a breech fetus at the threshold of viability, despite the belief that there is inadequate evidence in the literature to support this recommendation.     

臀先露、肩先露未足月胎膜早破对妊娠结局的影响

目的：探讨臀先露、肩先露未足月胎膜早破（PPROM）与妊娠结局间的关系,为临床处理PPROM提供参考。方法：收集单胎PPROM产妇235例,其中臀先露、肩先露并PPROM49例,头先露PPROM186例。观察两种类型PPROM的并发症及妊娠结局情况。结果：臀先露、肩先露组的潜伏期明显短于头先露组,其余一般情况与头先露组比较差异无统计学意义（P〉0．05）。臀先露、肩先露组AFI≤5cm、1minApgar评分≤7、脐带脱垂、死胎死产、新生儿死亡的比例明显高于头先露组（P〈0．05）。臀先露、肩先露是导致1minApgar评分降低的独立危险因素（P=0．021,OR=O．0821）。臀位、横位先露组与头先露组的剖宫产率、阴道分娩率比较差异有统计学意义（P=0．00）。臀先露、肩先露的产妇中行剖宫产者脐带脱垂、死胎死产发生率明显低于阴道分娩。结论：臀先露、肩先露PPROM更容易发生脐带脱垂、lminApgar评分≤7、AFI≤5cm、死胎死产,是1minApgar低评分的独立危险因素,因此一旦确诊为PPROM,且胎位为臀先露、肩先露,应给予及时处理。避免脐带受压,尽快行剖宫产,有利于改善围产儿结局。     

B型超声检查在臀位诊断及处理中的意义：附201例分析

本文201例单胎臀位在产前2周进行B型超声检查,为分娩方式提供多项参考指标.(1)臀位诊断准确率:B型超声诊断臀位与产时符合率达100%.(2)预测胎儿体重:B型超声预测体重与出生体重符合率为73.63%.(3)胎儿异常情况:201例中脐带先露17例,胎头过度仰伸1例.凡估计胎儿体重≥3400g、足先露、脐带先露或胎头过度仰伸者均行选择性剖宫产,使围产儿死亡率显著降低     

Changing attitudes toward mode of delivery and external cephalic version in breech presentations.

OBJECTIVES: To compare the attitude of gravid women in breech presentation towards external cephalic version (ECV) and mode of delivery between 1995 and 2001. METHODS: A questionnaire on ECV and mode of delivery was distributed to women in the third trimester of pregnancy with breech presentation, attending our departmental clinic for a routine check-up once in 1995 and again in 2001 in order to analyze changing attitudes. RESULTS: One hundred fifty-four women completed the questionnaire in 1995 and 127 in 2001. There were no statistically significant differences between the groups in age, gestational age, gravidity, parity, or level of education. In 1995, more than half the women (52.7%) had heard of ECV and 53.8% were willing to consider it, whereas in 2001, 73.2% had heard of it but only 23.9% were willing to consider it. In both groups, the women who were familiar with ECV were more likely to work outside of the home, have a higher level of educated than the women who were not. The women who were willing to try ECV were more likely not to work outside of the home, to consider their pregnancy low risk, and to opt for vaginal delivery (vs. cesarean section) if ECV did not succeed. The percentage of women who would choose planned cesarean section if the presentation remained breech was significantly higher in 2001 (97%) than in 1995 (64.7%). CONCLUSIONS: Attitudes toward breech delivery have changed since 1995. More women are aware of the option of ECV but are less inclined to consider it. Planned cesarean section for breech presentation is the overwhelming choice of women in general, with a significant increase in 2001 compared with 1995.